HRET Hospital Engagement Network Strategy Map

• • • •

Goals Reduce Harm: 40% -12/31/13 Reduce Readmissions: 20% - 12/31/13 1,200 hospitals submitting data - 12/31/12 50 case studies of improvement - 12/31/12

Strategies

Activities

DRAFT Measures

Obstetrical Harm • Elective induction compliance bundle • Elective Induction pre-39 weeks (Chart review) VTE • • Percent of patients with VTE risk assessment completed on admission VTE Incidence rate Surgical Care • Percent of surgeries using safe surgery checklist • SSI rate Adverse Drug Events • Percent of unreconciled medications • Adverse drug events per 100 admissions Pressure Ulcers • • Percent of patients receiving daily pressure ulcer risk reassessment Pressure ulcer rate per 1,000 days Falls • Patient injuries from falls per 1,000 days CLABSI • CLABSI s per 1,000 line days CAUTI • CAUTI appropriateness compliance • CAUTI rate per bed days VAP • Ventilator Bundle Compliance • ICU VAP rate per 1,000 ventilator days Harm Rate • IHI Trigger Tool (Chart review-4/12, 11/12, 5/13, 11/13 – 20 charts per hospital) Culture • • Percent of hospitals that have implemented a safety culture survey within last 2 years Percent of hospitals with improvement in safety culture scores Teamwork • Number of staff that have completed teamwork training Leadership • • Percent of hospitals reporting readmissions and harm rates to Boards Percent of hospitals with leadership incentives tied to harm and readmission rates Readmissions • 30 day all cause readmission rate OVERALL SCORE=Roll-up of the Measures

1. Engage Leaders

Driver: Engagement of leadership will ensure accountability of improvement and having adequate resources and attention

(Will)

• • Bi monthly feedback reports to SHAs Bi monthly feedback reports to Hospitals

2. Provide Best Practice

Education

Driver: Evidence and best practices of what works in different settings is needed

(Ideas)

• • • • • • Convene affinity groups for sharing (e.g., CAH, rural, rehab hospital) Monthly national webinars Subject Matter Expert Speakers Bureau Active listserve Robust hpoe.org website Link to National Content Developer website

3. Develop Improvement Capability

Driver: Ability to implement improvement is a needed skill for frontline staff/middle managers, other hospital leaders & SHAs

(Execution)

• • • Improvement Leaders Fellowship On-line training modules TeamSTEPPS

4. Implement Collaborative Improvement Projects

Driver: Peer to peer learning is an effective adoption of best practices method

(Execution)

• • • • CUSP CAUTI CUSP CLABSI National collaboratives/ Topics TBD State level collaboratives

National Plans

• Leadership Engagement • Best Practice Education • Improvement Leaders Fellowship • National Collaboratives

State Plans

Alabama: 29 Alaska: 11 Arizona: 32 Arkansas: 58 California: 288 Colorado: 70 Connecticut: 30 District of Columbia: 7 Florida: 88 Idaho: 10 Illinois: 203 Indiana: 115 Kansas: 87 Kentucky: 113 Louisiana: 88 Massachusetts: 78 Mississippi: 56 Missouri: 103 Montana: 26 Nebraska: 40 New Hampshire: 17 New Mexico: 23 North Dakota: 11 Oklahoma: 74 Oregon: 21 Puerto Rico: 65 Rhode Island: 11 South Dakota: 23 Utah: 8 Vermont: 11 West Virginia: 35 Wisconsin: 91 Wyoming: 9